Universal health care on the horizon

James Burdick

U.S. Chief Justice John G. Roberts Jr.and the Supreme Court have not only upheld the Affordable Care Act, they struck down a barrier to universal health care for Americans. Looking forward from the Supreme Court's decision, by defining the cost of expanding coverage as a tax, the court has moved our thinking toward universal health care as a proper cost of the country's well-being.

The Obama administration's defense of the individual mandate in the Affordable Care Act as a tax was widely second-guessed. Analysts saw it as a weak argument compared to the Commerce Clause justification. But framing the mandate as a tax was resoundingly successful for a couple of reasons. It probably won the day partly because defending the mandate only under the Commerce Clause — a nemesis to conservatives — would have been less compelling to this court. Taxation, on the other hand, is a foundation of federal power and hard to argue against. JusticeAnthony M. Kennedy implied as much (even though in the end he voted against upholding the Affordable Care Act), calling it the correct power, and Chief Justice Roberts, with his allegiance to process, was compelled to agree and therefore voted against gutting the ACA.

The success of this defense on the basis of the power of taxation contains great promise. It sets the stage for a national system covering health care for all.

The ACA does not get us there. But future legislation might specify more complete coverage for Americans' health care, and pay for this through a fund raised by taxation. It would be hard for a future Supreme Court, no matter how conservative, to be persuaded to take on a constitutional challenge to a law based on taxation that would provide a doctor for every American family, given this Supreme Court decision. So it is just a matter of time.

Of course, not everyone is in agreement yet. Since the Supreme Court did not uphold the requirement that states increase their Medicaid participation, some governors are dragging their heels. But what a deal they are turning down: complete federal funding initially, and 90 percent or more from Washington after that. It is hard to imagine even a particularly obstinate state holding out against participating for long as its citizens face the hardships of lack of insurance coverage while those in surrounding states are cared for, thanks to this federal commitment. Its bureaucrats will know full well that the cost down the road to a nonparticipating state from the loss of jobs and expense of unnecessary tests and treatments from failing to support timely, quality care will surpass the cost to the state of the expanded Medicaid program. Dogmatic bluster will eventually have to yield, moving us closer to universal coverage.

Beyond its specific provisions, the ACA produced momentum for reform. In fact, even if President Barack Obama were to lose in November, naysayers' hopes for the reversal of humane health care reform will not be realized.

Of course, the Supreme Court did not provide the money to expand coverage. But Americans now pay twice as much in insurance premiums and taxes for health care as is necessary for them to get quality health care. The money is there. Spending it wisely, with dedication to quality, will provide savings even given the challenge of coverage for all.

Actually, and despite criticism that the ACA does little to reduce costs, this law ultimately saves taxpayers' money. Cutting overutilization is a major goal. Unnecessary tests and treatments can harm patients and are a huge reason for our bloated costs. Quality care is not the excess care contained in a "Cadillac" health plan; quality is precisely the clinically correct test or treatment chosen by the doctor and patient together — no more and no less.

American medicine is already heading in this new direction. Informed patient choice, as championed by Dr. Donald Berwick, former Medicare and Medicaid administrator, and Dr. Jack Wennberg of the Dartmouth Atlas of Health Care, will improve quality and save money. To quote Dr. Christine Cassel, president of the American Board of Internal Medicine Foundation: "Rationing is not necessary if you just don't do the things that don't help."

Yes, there are special interests against reform. But health insurance companies have been grudgingly making some concessions to improve coverage. The American Medical Association reports that private insurer error rates in reimbursement to doctors and hospitals have now been cut from 19 percent to 10 percent, which saved the country $8 billion last year. Drug companies are taking on a greater role in achieving savings from generics. The majority of doctors favor reform, and the AMA recommends that everyone have coverage, as do many other professional organizations.

All of these developments recognize the value, and the inevitability, of progress toward an improved national system. The Supreme Court decision has cleared the way.

Dr. James Burdick is professor of surgery at Johns Hopkins University School of Medicine. He had a career as a transplant surgeon and served in the Department of Health and Human Services as director of the Division of Transplantation. He is writing a book detailing his doctors' plan for health reform. His email is jburdic1@jhmi.edu.